An Expatriate in the City of Dreams

Part One - Medicine

2006-02-14T09:53:00.000-08:00

I've only had time to write my impressions of Swaziland up till this point because of my lack of internet access. So I guess I should write some more concrete entries right now.

Firstly: No-one uses the term "AIDS" anymore. What they used to call AIDS is now WHO Stage 4 HIV Infection. Interesting, huh? The WHO stages are a bit more detailed and useful than the whole HIV/AIDS distinction. In a way it's a good thing that they've let go of that. AIDS is a pretty stigmatised word, and HIV sort of conveys a bit more hope, I feel. AIDS is a terminal illness. HIV is a chronic treatable condition. That sort of thing.

Secondly: Swaziland is not a rich country, by any means, but it is also something like the 3rd richest country in sub-Saharan Africa in terms of GDP per capita. Starvation is not a problem there. Everyone is NOT living in huts. There is no civil war. One of the biggest problems with the healthcare system is the lack of primary care- GPs and community services like nursing and physiotherapy. There is a SEVERE doctor shortage, much much worse than anything that Australia can complain of. Its capital is Mbabane, where we were living. The main export is sugar. There are a reasonable amount of expats, especially Chinese, sub-continental and white, but it's not as cosmopolitan as South African by any means.

I spent my days either at the VCT (care and voluntary counselling and testing centre, or basically "HIV outpatients") or the wards. I would say that my first impression of Mbabane Government Hospital was simple: "I could work here". Despite the high workload, the doctors were friendly and cheerful, going through their business with smiles and jokes, relaxed. The medical hierarchy really wasn't evident at all. Everyone worked together roughly as equals and the patients too were treated as equals. Apparently this is due to the local culture- respect is very important. People refer to each other as "ba-be" or "ma-ge"- sir or madam. Your patients will greet you heartily in the street having seen you in the clinic. "Hi Doctor!" I heard almost every day, grateful patients greeting my cousin, Priyani, who was also the head of the Department of Medicine there.

VCT, in a new building funded by international sponsors, was always chock-full. Unsurprising, really, in a country where roughly 40% of the population is HIV positive, I guess! They offered pre- and post-test counselling, free testing and follow-up care. So, Mondays and Thursdays were their busiest days, because they were previously the 2 days that VCT was open. Tuesday was paediatrics.

There were 2 doctors there, Dr Takuva and Dr Mlawanda who were both from Zimbabwe. Dr Mlawanda, who was a short, heavy-set guy, with a loud voice. curiously, wanted to be an ENT surgeon once but sadly ran out of funds for postgrad study. Dr Takuva was tall, slim and unconventionally handsome and was studying for his UK physician part ones. In between discussions of hepatotoxicity with antiretrovirals (HIV drugs) and regimens of TB treatment, we'd often sit there discussing things as diverse as the war on Iraq, implicit racism, TV and hospital politics. The friendly banter about US foreign policy flying between between Dr Takuva, a conventionally liberal guy who was anti-war and Dr Mlawanda who was pro-war often made me laugh! Dr Mlawanda had a habit of running off early every now and then. Dr Takuva only really escaped once, apparently to meet a lady friend...

So, the doctors sat in a room with 2 desks, seeing one patient each. As you can imagine, the privacy was not great. In terms of confidentiality, it is of course kept, and it's illegal to divulge someone's HIV status. However, I guess, they are actively encouraging people to admit their status and be open about it- for good reason. In a country with a high rate like this one, and also a lot of unprotected sex, that is important.

There was also usually a couple of Swazi girls there interpreting and helping out. However they had a habit of absconding, and in general the staff tended to try and get their relatives to the front of the queue, rather unfairly. But everyone was very friendly and were quite interested in having a medical student all the way from Australia- South Africa or Mozambique would have made at least SOME sense, seeing as Swaziland is such an obscure country.

I used to draw a bit when I wasn't doing any active learning. Just quickly sketching people's heads with my new fountain pen. I got a LOT better, too. The people in Swaziland were overall a good-looking bunch. Even though not all of them are beautiful, they have really even, well-balanced features. There's a surprising amount of variation in looks too, much more so than a place like Sri Lanka, where I guess people are inbred. Heh. So I became quite well-known for drawing, and the patients would jokingly ask to see what I was drawing!

Anti-retrovirals have really changed things for the better. It disgusts me that in the past they weren't available, because to tell the truth, in the current age, HIV is chronic and treatable, like diabetes, rather than a terminal illness. Not giving HIV positive people the drugs is akin to not giving diabetics insulin. I saw many patients who presented, really unwell, and now have their disease under control and are fit and healthy, though possibly suffering from side-effects of the treatment.

So, I saw several patients who were obviously very ill. You can sort of tell who has TB- they're totally emaciated, sweating heavily often. They look very unwell. I saw someone with probable cryptococcal meningitis- head cocked back, blank, staring eyes. The "crypto" look. There was a woman who came in with PCP- a form of pneumonia that people who are immunosuppressed can get. We saw her all the way from getting ill, her admission with severe shortness of breath, to her complete recovery. Babies, fat and healthy once their CD4 counts had recovered (obviously I did not see them all the way from when they were ill to when they improved- I was only there for 3 weeks). Needless to say, it was one of the most rewarding things- seeing that the access to drugs really really helped people.

It was also good to see people smiling and laughing. They don't show you that on the ads of starving orphans. But it's what really gets to you. A sense of humour indicates that there's someone just like you there. Someone who could easily be your mother, friend, son. Even could be you. It was nice to see the doctors and patients joking with each other. It instantly set everyone at ease. Made working worthwhile. Somtimes chilled you with the knowledge of the epidemic.

The paediatric days were depressing and rewarding. Kids with HIV look small and skinny. They lose weight for several reasons- chronic diarrhoea, other infections of the gastrointestinal tract, repeated infections in general, the HIV itself. They gain a lot of weight when they start HAART- highly active antiretroviral therapy. Though usually they are brought by their mothers or come in alone, from school, often a father, grandmother or another relative will bring them in because their mother (or parents) have already died of HIV. Or sometimes the parent doesn't care, for one reason or another (but that is rare). I wrote up several prescriptions to start kids on HAART. This feels so wrong precisely because these kids will have to take these drugs for their entire lives. Usually a combination of d4t (stavudine) which causes bad fat redistribution and peripheral neuropathy (tingling and numbness in hands and feet), nevirapine (NVP) which can cause liver problems and bad drug reactions and 3TC (lamivudine) which isn't so bad at all. Patients on HAART have to have their CD4 counts ("soldier cells"- they regulate the immune system and are what HIV attacks), the amount of virus in their blood, their liver function and other things checked regularly. So you can imagine that there was a huge line purely for taking blood from little kiddies. Who would either scream and cry and fight, which is rather distressing, also because it's quite dangerous because of the possibility of a pricking yourself with an infected needle, or would stand, serious and mute, bravely taking the needle without any complaint. Poor kids. It was heartbreaking.

There was a small girl of about 8 or 9 who I actually first saw in the STD clinic. She was brought in by the childcare worker who she was living with- her grandmother asked her to look after her because she (the grandmother) could not control the situation at home, where one of the older male relatives was abusing her. The girl was this gorgeous, shy kid, who eventually smiled me possibly the biggest smile I have ever seen. She needed an STD screen. She had also contracted HIV, so we saw her again in the VCT for follow-up. She recognised me and was curious about my drawings, so I asked her whether she wanted me to draw her a picture of herself. Grinning broadly, she nodded a yes. So I drew a quick sketch of herself and gave it to her. She seemed really happy =). Later that day in town, she and her guardian saw me randomly and called out to me and said "Hi!". It was a nice feeling.

And incredibly depressing. Chilling. Sigh. Everything that I did was bittersweet.

The ward was also very interesting. I was following Dr PF Dlamini, a Senior Medical Officer (as opposed to Dr D Dlamini who apparently didn't turn up as much), who was Swazi. He'd wanted a job in South Africa but they had told him immediately "your country needs you more". So there he was in Swaziland.

As usual the male ward smelt significantly worse than the female ward. For whatever reason, the male ward, no matter where you are, smells distinctly of stale urine and body odour. It was pretty crowded, similarly to Sri Lanka, and there was the occasional patient who was on a mattress on the floor. Often hooked up to a drip, no less!

90% of the patients on the ward have HIV. A lot of admissions for TB, for example. Tuberculosis is a disease which is hard to catch and doesn't usually cause symptoms in people who get it, oddly enough. As long as they have a healthy immune system that is. The moment that ones' immune system is laid low, especially by HIV, TB can't be contained properly by the body, and it causes disease and can even spread easily outside the lungs, depending on how bad the immune system is faring. People with uncontained TB are also more infectious, for obvious reasons. There was, of course a large variety of patients. While many were suffering from HIV-related conditions, you definitely could not make the assertion that all were. There were several cases of liver failure (for reasons that become obvious later in the piece- drugs, infections, etc). Many admissions for anaemia (likewise). Several stroke patients. Several people with rheumatic heart disease or heart failure- conditions that do not really affect the young in Australia, as streptococcal sore throats are treated with antibiotics promptly. There were even some pretty odd cases- a case of Sydenham's Chorea, a disease which causes abnormal movements following a streptococcal infection, and a case of neurocysticercosis where pork tapeworms end up forming cysts in your brain. So it wasn't all HIV.

There was a patient on the ward who was admitted for severe anaemia. He was in Stage 4 of HIV, and he was only 19 (he looked younger though). He could barely eat because of mouth infections and was pretty hungry. This guy needed a blood transplant urgently. However, because of HIV, and because of the high demand because of severe anaemia, the situation was dire. His life was saved for the moment by the fact that they managed to get him 2 units of blood. But he definitely needed more. He was very week. It was pretty depressing, seeing him. He wasn't much younger than me. He was doing pretty badly. Poor guy. His mother came in every day to see him and help out.

It's interesting, HIV is primarily a disease of the young in Swaziland. There are certainly some people over 50 who get HIV, but the line to VCT is chock-ful of young people, whereas the Hypertension clinic line is full of old people. Yes, they get hypertension and diabetes and heart disease in Swaziland. Not everyone has HIV! More than half don't. However, it's really changed the face of medicine there, given that it is probably the most common chronic condition and has so many effects on disease. You could easily write an entire textbook to go along with the usual Textbook of Medicine and call it the Textbook of HIV Medicine. It would have exactly the same chapters in exactly as much depth and it would be what they use in countries with a high prevalence!

A note: the regimens used in Swaziland are different to those used in the West. Access to drugs is one issue- it depends on which drugs are affordable or donated- and also some drugs are contraindicated because of local conditions. They use nevirapine instead of efavirenz first-line because of the high rate of pregnancy. They use d4t instead of AZT because of the high rates of anaemia- I saw several admissions to the ward per day with anaemia because of AZT suppressing the activity of the bone marrow. Anti-TB treatment also causes issues because TB drugs and antiretrovirals are toxic to the liver. Hepatitis B is also quite common as is the use of traditional medicines, which also have liver toxicity. So I asked Dr Dlamini what he would do if there was a patient with HIV who was on Anti-TB treatment, had suddenly fallen pregnant and had anaemia to boot.

"That woman clearly has severe issues!" was his astute reply.

The other place that I hung out a bit was PORECO- which was a pilot research project in Swaziland on implementing a low-cost intervention to prevent the transmission of HIV from mother to child (vertical transmission). With no intervention, the rate of transmission is roughly 50%. Very high. And due to probably three mechanisms of infection: 1) A new infection in the mother leading to the foetus getting infected; 2) The delivery itself; 3) Feeding from infected breast milk. Until fairly recently with modern interventions, the rate in the West was actually around 5-6%, but now is more like 0%. In the PORECO project, they counselled the mother (and if possible the partner) extensively, monitored her health and progress, gave a dose of anti-retrovirals to the mother and child before/after delivery, and advocated either formula feeding or exclusive breastfeeding with abrupt weaning.

"BREAST MILK?!?!" you must all be crying out by this point. Well... yes. Some preliminary research in South Africa suggests that exclusive breastfeeding (no extra stuff like water or juice or formula) actually has a rather low risk of transmission. Mixed feeding, however, because of increased permeability of the gut, supposedly is what carries this high risk of transmission. Interestingly, the PORECO project supported this finding. Of breast-feeding mothers, no babies who were HIV negative at 6 weeks became HIV positive (suggesting that those babies who were HIV positive probably got the disease during delivery). Why is this all important? Because in many places, including Swaziland, clean water and hygiene can be an issue, and these things are vital if you want to formula feed your child. In fact HIV negative formula-fed babies often die of malnutrition and dehydration secondary to diarrhoea. So, in these settings, exclusive breast-feeding may in fact be worth it because the benefits significantly outweigh the risks. Of course this is all very new stuff, and it remains to be seen whether it is borne out by future research.

The rate of HIV transmission was actually 6-7%, comparable to the old figure in Western countries. Which suggests that the main risk factors are the delivery itself, and possibly some foetuses catching HIV in the womb. It's nice to see low-cost interventions making such a big difference.

It is pretty amazing seeing simple things like drug availability and other interventions making a big difference, and this is what is hopeful about the situation. My cousin has done a LOT for the people here- she set up the HIV clinic in order to try and treat the complications of the disease even though anti-retrovirals weren't available back then, even though people said it was pointless. As a result Swaziland became one of the first developing countries to receive low-cost drugs. So it is heartening to see that in some places at least, a doctor really CAN make a difference. To an entire country, even! It is good to see that even with such poor odds, things are starting to improve. However obviously people are both uneducated about HIV and/or do not care or are fatalistic about the disease. So it is both encouraging and depressing. I think that is a lot of what I felt about my experience, medically speaking. It was bittersweet. Very bittersweet.

I think it is absolutely criminal how slowly the drugs are reaching the people who need them. How little the developed world is doing to improve the factors that make HIV infection so widespread and deadly- provision of healthcare and education and economic conditions and even in some areas, water and food. I also think that we in Australia have no real right to complain about the healthcare system or doctor shortages (unless we're Aboriginal or living in a truly remote area). It is also amazing how much I have learnt in such a short time about medicine and thinking for myself and on my feet, about clinical medicine, and about the ability of people to actually make some kind of difference and have some kind of meaningful effect on society. I've learnt to stop relying purely on investigations and to actually trust my own clinical judgement. I've even helped make decisions and done things I would not have had the opportunity to in Australia.

So I propose something rather unusual. I would like very much for developed countries with good postgraduate training programs to send their registrars to resource-poor settings for a rotation so learn how medicine is practiced over there. To improve their clinical skills, to learn to think for themselves. To see how bad things can get, to start to see their patients as people again. To know what human suffering is. To see that there is a possibility of actually having an awesome and satisfying job where you are valued as a worker. To really help people. I think it would definitely be a mutually beneficial situation for all parties involved- Australia gets better trained doctors, poor countries get more medical staff and doctors get better experience. It could even feasibly be run as an exchange program, if the doctor shortage is a pressing concern.

Whatever it is, there is good work to be done. And I feel like I could, as I said, back then "definitely work here."

Swaziland! And some other random notes.

2006-01-19T05:02:00.001-08:00

So, here I am in Swaziland. One of the countries with the highest HIV rates in the world. One of the richest countries in sub-Saharan Africa. A very different place than I would ever have expected from that description!

The people are... hot. And friendly. And very funny. I think... you can stare at pictures of orphans with HIV all you like, but nothing will prepare you for, well, dealing with people. Individuals. Or a country rather than a continent. I was fully preparing to NOT be facing a stereotype. But I didn't realise it would be as idiosyncratic as it is.

This place is so quiet that the headlines here scream of the drabbest stories. "Man has sex with dog", "13 year old girl reduced to ashes". Everyone smiles at you and says hello. In a sincere manner. Amusing things happen on a regular basis. The doctors tell jokes about sex and religion. Children waste away because of HIV, and there you are, writing a prescription for HAART (combination therapy for HIV), thinking "there is something wrong with this". Babies gurgle, relieved after the doctor has, with difficulty, taken some blood for a CD4 count. It hails, and a girl working in VCT (HIV outpatients) accompanies me with an umbrella to where a research project is based, while we hope to avoid the lightning... Lightning causes a ridiculously high number of deaths in this country.

It's a good place. I could work here. People are overworked, but relaxed. It's depressing but fulfilling. It's... somewhere where I would be needed. Though, definitely a temporary stop on the way to the grave. But I really like it here.

My cousin and her family are very cool. I'm having a great time, and I'm not lonely at all! She's a bit... homophobic though. But in a way, to say that would be looking for things to be wrong with being here. Which there really aren't :).

Oh, and I went shopping in Singapore. Yay!

Last Day

2006-01-19T05:02:00.000-08:00

From Last Week:

This is my last day in Sri Lanka, or to be more accurate, my last few hours. I shall be leaving tomorrow morning at a “sprightly” 7am.Do not be fooled, dear reader, for I have accomplished much over the past two weeks, despite my lack of diligence in regards to posting on here…My last 2 weeks in Sri Lanka were made a lot better by the appearance of a class full of local final year students, as well as two Melbourne Uni students in my year who were similarly on elective! They were fantastic, funny, good company, full of life, great translators and even better friends. If it were not for them, I would have been homesick and unhappy over here. I now have several email addresses and postal addresses shall soon have, hopefully, a copy of a photograph of 20 or so beaming medical students, all in their shiny white coats!I had a great time over here. From the sibling rivalry and mock fights and banter and random tickling with my little cousin Sasika, to the herd of buffalos that randomly grazed on our road, to the chaotic bus changes every day, to the lunchbox filled with delicious rice and curry and lovingly wrapped in a checkered cloth square by my Aunt, to the chocolate milk that tastes far better here… I have had what can only be described as a vivid and unforgettable elective.This morning, I arose from my bed in Kandy for the last time. My bags were packed meticulously, all my clothes (for a change) pressed neatly. We ate quickly before setting off. It has been raining, on and off, rather heavily, and the sky was heavy with thick grey cloud. We drove through the city of Kandy, which I now know well, past Mahaiyawa train station, over the hill, past the clock-tower, past the Kandy train station. Followed the tracks that ran alongside the new road to Peradeniya, and I saw the University and the hospital for the final time, as we turned away from the city. Down the famous road that winds down to Colombo- a heavy fog clung to the mountainside as we left that mountain citadel- and past the many stalls selling clay pots, then wickerwork, then cashew nuts, then (oddly, bizarrely) blow-up cartoon figures, empty because of the Poya day (Buddhist full moon holiday). Finally we had descended the mountain, and the road drew us closer and closer to Colombo. Heavy traffic went the other way, Colombo-dwellers heading through Kandy to Bandarawella, Nuwara Eliya and other places for the long weekend. Finally, as the numerous small towns we passed merged together into big city, we entered Colombo.I have seen my relatives in Colombo for the last time. As usual, I regret the brevity of my stay here. “Next time”, is what we always say.Tomorrow I shall be having a 12 hour stopover in Singapore during which I am likely to go shopping. In roughly a day and a half, I will be in Swaziland, meeting my cousin, for one of the first times in my life…

A Day in the Life

2006-01-03T02:01:00.000-08:00

My shoes shined to a full gleam, my trousers pressed, my shirt ironed. Face scrubbed, teeth brushed, hair combed and tied up. Bag packed- rice and curry in my lunchbox, an apple, two notebooks, a bottle of water and an umbrella. This is how I started the day. I said a rushed "good morning" to my uncle, aunt and cousin Sasika. I sat to breakfast, ate my bread and cheese hastily, knocking back a couple of glasses of water. My uncle quietly read the paper, and my aunt rushed to get things ready. Sasika and the servant, Arungam bickered as usual, a strangely comic banter. My uncle, aunt and I exchanged a look of amusement and could not stop ourselves from laughing heartily. I finished eating, said a quick "see you later", and stepped out the door...

Our house, a new, affluent one, sits on a hill, overlooking an area that sits on the borderline between slum and poor neighbourhood. A designation of "slum" is, I believe, somewhat suspect, as most of these cobbled-together dwellings in fact have a television, all of them have electricity, and there is ready access to clean water and sanitation.

(A side note: Interestingly, Kandy is a racially diverse area. There are large numbers of Tamil and Muslim people here- Muralitharan (who is a Tamil) is probably the most famous alumnus of St Anthony's College in Kandy. I have several half-Tamil half-Sinhalese second cousins in Kandy, even!)

I walked briskly down to the bus-stop. The buses here, noisy, hot and packed with commuters, run every minute or so. I waited for a bus that was fairly free of congestion, then hopped on. I managed to squeeze myself into a seat within a couple of minutes. I got off near the clocktower, caught another bus that was heading to Peradeniya, and daydreamed some more.

Soon I was at the hospital. Today was the second day that the final year students would begin the last of two medical professorial appointments. We had a brief tutorial about pyrexia (fever) of unknown origin while we waited for one of the students to interview a patient with chronic renal failure. I surprised myself by knowing many of the answers. I was on fire! The student finished writing his history up, and we proceeded to the tutorial room...

---

"So, tell me what else can cause loss of appetite, nausea, vomiting and malaise."

The registrar, our lecturer, narrowed his eyes, focussing tightly on the student.

"Ummm..."

You could almost see the beads of sweat on his brow. The student fidgeted nervously. His history was not up to scratch and the attention of the class was upon him.

"Anyone else?"

The classroom was almost silent, nervous whispers of thoughts passing back and forth like ripples in the current. Tension so thick you could cut it with a knife. A thousand answers rose in my head and fell back again, defeated.
The creak of the door opening. We turned to see that it was none other than...

"Brendan Whiting?!?! What are you doing here?"

So it seems I am not the only Melbourne University student in my year doing an elective here- who would've thought?

Various Things

2005-12-28T20:54:00.000-08:00

OK, so the weirdest thing just happened. Apparently Suji, the Canadian elective student who's here with me was trying to take a photo of the hospital and ended up getting chased by the hospital guards (who, by the by, carry guns). She just came in here, visibly shaken and crying. How absolutely bizarre. I mean, I guess they would have misinterpreted what she was doing as a security risk, but it seems rather callous of them. Suddenly I feel a lot less happy to be here. Things like that just end up increasing your sense of alienation.

So, in Sri Lanka, there is often overcrowding in hospitals, and patients end up with no bed, either on the floor or in chairs. A couple of days ago, a man who was in the "local ICU" (like a Coronary Care Unit, but in the ward itself) who had had a heart attack was moved to one of the beds in the ward, thus replacing a patient with valve disease. A loud argument erupted between the two patients when this happened, the man who was losing his bed accusing the other man of deliberately taking his bed and being ungrateful.

I now also understand why they have male and female wards. It's because rather than having rooms of 2-4 patients, basically the whole ward is open, with many beds and pretty much zero privacy. There are also mosquito nets above each bed, to prevent the spread of diseases such as dengue and malaria.

It seems like my trip to Colombo might be a bit of a waste, since I won't be able to meet up with at least 3 of the people I was planning to catch up with. Stupid New Years' weekend.

I miss sushi. I I miss videogames. I miss my mum. I miss videogames. I, I, I miss my mum. (If you didn't get the reference, all I can say is, "maybe when you're older").

Good Day.

2005-12-27T23:14:00.000-08:00

"God it's been a lovely day
Everything's been going my way
I took out the trash today and
I'm on FIRE...

...so you don't wanna hear about my good day?"

I can't get that song out of my head! Well, the whole Dresden Dolls CD in general. It's on repeat in my head, thus replacing Cake's "Haze of Love" and The Killers with "All the things that I've done" and "Love song for a girl" by Diana Ah Naid. Sometimes I get slightly creeped out when I have a series of songs in my head like that... is my head trying to tell me something?

And in other news, I'm having a good day, and I'M ON FIRE! Wow. So, ever since I worked out that I should just follow this particular registrar, who is, by the way, an excellent teacher, suddenly my life improved. I got to see some pretty interesting stuff again today and learn things. Then I went off to a lecture on Polyneuropathy (grrr... now I remember why I hate neuro so much) and got an invitation from one of the Anaesthetists to get taught intubation and spinal blocks and other kick ass things! I feel a lot less useless and overwhelmed now, which is good.

Given that I started my day with "I don't want to go to school"-itis (stomachache subtype), I'm quite happy with the way that this has all turned out.

Let me just make it clear that in my last post, I was referring to a phenomenon which only affects a minority of people- there aren't that many people who are weird and hostile about the foreign-born Sri Lankan business, it's just a few fairly loud ones more than anything. Most people are vaguely curious and very friendly.

Anyway, not much more to say. Off to Colombo this weekend. I'll try and update before that.

First day of General Medicine

2005-12-26T23:05:00.000-08:00

I'm officially homesick. I miss my computer and my friends and drinking and good coffee and decent films and TV and the English language. So today, I'm just going to complain on here.

So, I've finally started. *sigh*. I'm feeling exhausted, and it's only lunchtime! I think I managed to join three ward rounds, during the course of which I learnt the following great lesson: Consultants make crap teachers, and registrars make good ones. For the uninitiated, consultants are specialists, and also at the top of the medical food-chain; registrars are specialists-in-training and do most of the day to day management of the ward. For whatever reason, the registrars seem to be a lot more interested in teaching and explaining and have a better grip on what sorts of things you should learn. My theory is that consultants just live in another world, really.

I suppose things will get better once there are other students around. For now, it's a bit crap because I'm the only one. I already feel very much like I'm back in the grinding mill that is my chosen profession. What does that mean? I already feel stupid, having been asked a whole lot of questions that I should know the answers to, but don't, on account of the fact that I wagged renal and neuro. It's a bit crap when you work out that proximity to your future job is inversely correlated with your self-esteem.

On the other hand, I managed to see a fair few cases of dengue fever, something I've never seen before, as well as a case of Takayasu's Arteritis, something I may never see again.

I keep getting the distinct impression of a certain amount of hostility towards foreign-born Sri Lankans here. Something along the lines of how we're all arrogant snobs with no idea of the local culture or the way in which people live. To add insult to injury, we also haven't bothered with learning Sinhalese properly, because we're "too good" for it or something. Whatever it is, it's starting to annoy me. I've heard a couple of remarks about what foreign medical students are supposedly like already, as well as managing to overhear no end of comments made by other random people in Sinhalese, a language that I can understand perfectly well. I read a review of a short story in the Sunday paper which was about how one of the characters, a foreign-trained doctor, is totally out of touch with the local culture and dehumanises the patient, who is from a remote village. I find it outrageous to assume that because I don't live here that I know nothing of the culture and have a high-and-mighty attitude. I've spent a fair chunk of time here, over many visits, I've spent a large proportion of that IN villages, and I certainly understand the culture here well, as well as being able to understand Sinhalese. To be perfectly honest, I've met many people from Colombo who have far less knowledge of the true state of this country and its people than I do. Hypocrites.

We (my uncle, aunt, cousin and I) went up to Nuwara Eliya on Sunday with Iresha, one of my second cousins. My 9-year old cousin, Sasika, kept trying to bully me the entire time. Heh. It was a fairly good trip. Nuwara Eliya is at a bit of an altitude, so is about 10 degrees cooler than Colombo. As a result, all of the European-type vegetables and plants are grown there, and it is full of pines and other coniferous trees. We went to a stuffy establishment for lunch, of the kind that is mostly frequented by rich tourists and rich people from Colombo. An oppressive silence hung in the air, as thick as a velvet curtain and just as old-fashioned (to use a Dire Assassin-ism). Our (whispered) conversation went a little like this:

Me: Are we allowed to talk in here?
Iresha: I have no idea!! It's so quiet!
Me: I'm too scared to use my voice.
Iresha: Maybe we should whisper?
Random tourists on the other table giggle

Some woman also asked my relatives if I was Indian. Then we stole some cacti. The trip to Nuwara Eliya, one way, was 3.5 hours or so, despite it being only 80km from Kandy. As a result, we were exhausted by the time we returned home.

I've been alternately hot, tired and ridiculously hungry since getting here. I keep going to bed at 10pm, exhausted. I'm clearly not used to 8-hour sleep times.

I'm going to buy myself a calling card today.

A Life Less Ordinary

2005-12-22T23:16:00.000-08:00

How do I explain how Sri Lanka is alive in a way that Australia is not? Perhaps it's just the crowding, the heat, the chaos. Whatever it is, there is life everywhere, the streets are packed and busy, there is culture all around you, all the time. Cobblers on the pavement, fixing shoes, street vendors selling guavas and mangos at the top of their voices, three-wheelers (tuk-tuks) winding in and out of traffic, rickety buses squashed with people. The heat. Random goats, cows, dogs, cats and chickens. Blue kingfishers and other tropical birds. Hordes of crows picking at piles of decaying rubbish. Bus conductors calling out their bus destinations: "Akurana akurana! Katugastota! Akurana!".

We saw a water purification plant and came up with many ways to dispose of people. There were the "rapids of death waterfall manhole", the "mustard gas chamber", the "skirt-eating fan of doom" and the "sludge bucket". We hope to return some day to commit many a murder, some of which may be featured on such British shows as "Saturday night murders", "A murder too far", "Murder, a drink with jam and bread" and "the sound of murder". I can't believe this, but due to my unoriginality that entire paragraph will be reproduced on Snipergirl. Anyway, what was I saying? Sri Lankan plants are dangerous!

I am no longer sleeping in the same room as my grandmother who sleep-shouts. This is very good, as now I can actually get some decent uninterrupted sleep. In fact last night I was very happy to receive all of a sound 9 hours or so. While I had some odd dream featuring pretty Malaysian girls kissing each other and woke up feeling groggy as usual, the effects of my increased sleep is profound. I can string sentences together again!

We have also determined that the worst thing that could ever happen is going through Labour Colour Oedema Anaesthesia Theatre at the Centre for Paediatrics (OK, so maybe I went overboard with the Brytysh speeling, but really what I meant was labour, as in the pregnancy, not as in the work or the politics. Isn't it a shame that you didn't end up at the Women's Hospital, you ended up at the CHILDREN'S?!?!?!), while you're passing a kidney stone. Then, suddenly, you get a 3rd degree perineal tear. Then you get pyelonephritis (kidney infection). Then you have an asthma attack. So your obstetrician decides you're better off if you have a caesarian, making all that pain and suffering a bit, well, redundant. Then they shatter your kidney stone with ultrasound at the same time (this is the only happy part of this story). After all of that, you manage to get an amniotic fluid embolism, which manages to give you disseminated intravascular coagulation (DIC or basically having so many tiny little clots EVERYWHERE that you can just bleed to death). Then you die of strokes. The end.

"Thilini just said that it is ok to make fun of dead people ie if this actually happened to someone...she is going straight to hell in a handbasket!!!!!!!!!!!"

Clearly I have been having too much fun. Till next time!

I PASSED!

2005-12-21T01:39:00.000-08:00

I passed med!! In fact I got an H3!! A middling H3, not just a scrape-through H3!! And I got depressed, had bad stuff happen to me and took 5 weeks off class no less!!

THIRD CLASS HONOURS WITHOUT EVEN TRYING! W00T!!

The Girl and the Small Umbrella

2005-12-20T00:56:00.000-08:00

Kandy, the old capital during the days of the last Sri Lankan Kings, is a small city in the High Country (it is inland and at a higher altitude- as a result it is also much cooler, temperature-wise). It has old, narrow streets and buildings dating from colonial and pre-colonial times. The roads are thick with chaotic traffic. The slightly worn buildings are faced with busy, narrow shopfronts that sell all manner of goods- jewellery, watches, clothing, electronics, toys, food. It almost seems to be from another decade- the busy streets, the men in short-sleeved shirts and black trousers, the women in long flowing skirts and short fitted blouses.

Today it rained, fat raindrops pounding the city and turning me (dressed, once more, in my overcoat as it is rather cold these days) sodden. Pedestrians streamed past one another on the pavements, determined, carrying an assortment of umbrellas, and occasionally straying out onto the road in order to cross. I made my way hurriedly, bent over in the rain, to the umbrella shop. It was congested with customers, unsurprisingly. I pushed my way to the counter and perused the merchandise. There were no small, conservative, black umbrellas of the sort I was seeking; no. The plain ones were large men's umbrellas, and the small ones were ornamental and feminine.

One of the small umbrellas caught my eye- it was silky black with a red centre and patterned with small flowers. Opened up, it was bright, bold. Though perhaps a little garish, it seemed almost like it should be mine. I thought I would peruse the other umbrellas further. I came back empty handed. By this point another woman had "my" umbrella in hand and was deciding between it and a more drab greenish and somewhat old-fashioned one. To her, I feel, disadvantage, she ended up choosing the other umbrella, and handed me "my" umbrella with a smile. I bought it, and walked out, with this odd umbrella, quite happy.

I'm not sure what drew me to this umbrella. Its colouring perhaps? I have always been a fan of black and red. Or perhaps the ring of flowers that somehow reminded me of cherry blossoms, or maybe it was the small ornamental handle, in a delicate shade of blue-green. Whatever it is, it was an umbrella that stood out, even among the many designs and patterns of Kandy City. It was, oddly enough, very me. Even though it was this delicate, flowery piece. It was me.

What else? Some guy who seemed either sleazy or dodgy directed me to a cobbler and did not leave while my shoe was being mended. Wanker. I caught yet another packed bus from the chaotic bus-stop near the clocktower to the University. The crowding makes the bus smell intensely of stale sweat. Even on a cool, rainy day such as this one.

At the university, I discovered a building that was almost exactly the building from one of my dreams. It even overlooked rooves in the same way. The only thing it lacked were the abandoned dormitory rooms and cracked, mouldy bathrooms. The ELTU building (English Language Tuition Unit I think?) of the Medical Faculty. It was this very intense feeling of recognition- though I have never been to that part of the University. A similar thing happened to me when I went to the Flinders Street/Wellington Parade end of the Fitzroy Gardens. Odd.

Need to go and pick up my white coat from the tailor.

Till next time!

A hectic few days...

2005-12-18T22:01:00.000-08:00

What can I say, it's been an interesting time. We had the almsgiving for my grandfather's 3 month funeral anniversary. While this may seem a little inappropriate, I have to comment that I managed to fail hopelessly at my allotted task of helping out as a close relative. My mother's cousins' daughters were, however, ruthlessly efficient machines when it came to preparing the ceremony. They packaged, served and prepared with professional zeal. Whenever I volunteered my services they had "already finished" or I was more hindrance than help. It disappoints me also that I have forgotten a lot of the traditional ritual-type stuff. I had to be corrected several times on my actions. I feel a bit hopeless, really.

It was not a particularly solemn ceremony (though, nor was it celebratory in mood). On the night beforehand, many relatives (but not all) arrived. Several monks chanted Buddhist scripture in Pali (an ancient language), we took the five precepts and one of the monks gave a sermon. From what little I could gather, it seemed to be partially about the dangers of materialism and pop culture, which seemed particularly inappropriate as my grandfather was 91 and quite obviously not interested in hip-hop, metal or the like. He was also fairly verbose- I prefer my monks pithy, and with more interesting philosophical points. After the monks left, we had dinner.

The next day, all of the relatives who were attending arrived. Most of my mother's cousins and their families were present (as well as closer relatives) and even 2 representatives from my father's family came. Preparations were continuing in earnest. There was a short recitation of scripture, we took the 5 precepts once more, and the most senior monk spoke a little about my grandfather and his life. After they had been served and offered their meals, there was a small ritual that is done whenever a death is marked. A small vessel was placed on a plate. All of the close relatives- my uncles, aunts, cousins, grandmother and myself- slowly poured water into this vessel, as the monk chanted. The water trickled and filled the vessel, slowly, until finally it overflowed onto the plate. In a way I suppose one can think of life as being similar to this- it fills slowly, and as you age, tension within your body and soul rise until finally there is that spilling over. Death.

We ate afterwards. I spoke with many of my relatives- many of whom I could not remember save recognising their faces. To be fair, I have only met most of my mother's cousins on possibly 2 or 3 other occasions in recent memory- at my cousin Pubudini's wedding, and at my grandfather's 90th birthday.

I also met one of the neighbours of the uncle (Punchi Mama = mother's younger brother) who I am staying with. He was a doctor. And boy was he the slightest bit of a wanker. He asked me how many distinctions I had.
"Well, seeing how they only allocate 4 of these per year in our year level of 250, I would say... none."
Heh. That felt good. Well, kind of. People have been telling me all week about how I should be planning my specialisation right now. I tell them, usually, though in less coarse language, that I can't be arsed right now. Honestly, my love for medicine is at some kind of dire abyssal nadir (dig those words, man). Pubudini asked me what my plans were, and I said something along the lines of working for a couple of years, trying to finish writing 2 novels and then travelling. And suddenly, as simple as that, I knew it was true.

I have been feeling a nice feeling of contentment, rightness and peace since of late. A feeling of elation, and joy of living. It is the way that I have been feeling for much of the year, but that I had abruptly lost somewhere in the mid-year. I thought that this sublime feeling of grace and simple happiness was lost to me, and this depressed me further. And yet. It has crept up on me once more. An ability to see the good in the world and to sense what is true and right. Taoists would explain this as living "the Way", and I would perfectly agree with this. It feels right to be where I am, doing what I am doing right now, being who I am.

I "began" my elective today. There was much rushing around, trying to find various departments. After obtaining a letter and my temporary student ID we finally found our way to the Consultant Physician. She was seeing patients in the most overcrowded out-patients I have ever seen in my life. People had barely a space to sit amongst the throng. There must have been a good 200 people in there. I finally got a chance to speak to her. Unsurprisingly, I was shafted to Community Medicine, as this is the holidays for the clinical students. Community Medicine really is "HP [health practice] in Sri Lanka". We're with the 3rd year kids, who are pre-clinical. I've met the other elective student here, who is from Canada. She seems pretty cool. Apparently this elective is slack as, because of the non-teaching period (and also because Community Health is really mornings-only). I anticipate many days spent down in Kandy sipping a latte (if I can find one). So. Community Medicine for a week, then General Medicine for the other 3 weeks. Right. Hopefully I'll get to see some cool stuff when the other students are back (in 2 weeks).

I have free internet access! I'm sitting in the medical faculty computer room (or "e-library"). In socks. Very quietly. Because not only do we need to remove our shoes for some bizarre reason, but we are also not allowed to make any noise. Just now we got sent a warning because the Canadian girl and I were being too loud. It's a bloody computer lab for crying out loud! Honestly! Interestingly, the University of Peradeniya has possibly the only dedicated broadband line in Kandy, through the Engineering Faculty. Everyone else uses dial-up. I was convinced that broadband would be accessible for free at the University, but no-one else believed me. Oh well. It pays to be proven right.

So, evidently my life has gotten fairly interesting, possibly to get more boring very soon. I hope I'll be able to find more books to read in the meantime- Nietzsche can be a bit heavy for 8 in the morning.

Made It!

2005-12-17T08:51:00.000-08:00

So, here I am in Kandy. It's very humid, as it's the rainy season, and rather cool. I am even wearing a long-sleeved top! I arrived yesterday after 23 hours of straight travel, very very tired.

I had to wait a good long while in the check-in queue in Sydney- International Check-in may as well be a code-phrase for "most tedious and inefficient process on earth". On the flight up, on Singapore Airlines, I sat next to a gentleman of voluminous girth and a rather creepy touchy South African couple. I was hemmed in between bulk and inappropriate affection. I watched "The Edukators", which, thankfully, had a happy ending (I was in some sort of a mood- don't ask).

I managed to sleep rather soundly for 4 hours. I have discovered the most comfortable way in which to sleep in an airline seat in economy (this requires 2 cushions): One must first recline the seat back fully, then place the first pillow in the small of your back, with the other pillow slightly to one side beneath your head so that you can wedge yourself against the armrest and snooze comfortably. Singapore Airlines has great entertainment too- I had my last listen of "All the things that I've done" and "Everyday I love you less and less" on the flight up. I then had just enough time to dash off an email in Singapore before boarding my Sri Lankan Airlines flight to Colombo.

Sri Lankan airlines usually provides good food and service, however this time I was disappointed by surly attendants and mock Chinese food. Where was the curry? I have NO idea. I sat next to some total weirdos on the flight. They obviously did not use deodorant, and had brought on board two food parcels for themselves. Fair enough, perhaps they assumed there was no meal provided. However, even after an airline hostess pointed out there was a meal provided shortly after take-off, they continued to gorge themselves, eating with their hands. On an international flight. For crying out loud, this isn't Virgin Blue! Then as we were landing, instead of handing in their headsets, they surreptiously turned up the volume on them and hung them up on the tray tables. The air hostess had to yank it off. Twice.

It was an overcast day as we cruised over the tops of hordes of coconut trees and landed at Katunayake. Was met at the airport by Loku Mama (Sinhala for Uncle- meaning either your mother's older brother or father's older sister's husband). We chatted about politics and various other topics on the way up. Those Australians among you will be amused to know that he wanted to know about the Sydney riots. Felt rather ill on the way up and had to purchase some antacids, a month's supply of ranitidine (suppresses acid production in the stomach) and an asthma "preventer" inhaler. The inhaler was the killer, costing a cool AU$8. Everything else was so cheap that I'm tempted to stock up on them here.

I'm feeling very overwhelmed by everything right now. As my grandfather's 3 month anniversary of death is tomorrow, many of our relatives have gathered for the almsgiving ceremony to mark it. It is a big, complicated event, and everyone is rushing around. I feel at very much a loose end, and though I have offered my help, I feel that I have been more of a hindrance than a help, and that I help best by staying out of their way, which is rather depressing. My grandfather's death still has not really sunk in, even though we were once very close. I am not certain why.

I have already had a question about whether I have a boyfriend. Oh no. It makes me really quite tempted to marry someone in name only, just to satisfy everyone. Or just tell them I'm not thinking about it till I turn 30.

I start on Monday... I'm slightly afraid...

Sydney!

2005-12-12T21:32:00.000-08:00

Today is the first day of my travels. I flew to Sydney this morning, sleep-deprived and groggy, lugging a suitcase with only one wheel and filled with books and clothes. I left Melbourne in a mad rush, after a week of partying, drinking, friends, sex, confusion and other delights...

I slept on the Skybus, in the gate lounge and in the plane. My father met me on the train and brought me to our new house, now fully occupied. It is a large one, and the rooms hide away from each other despite their closeness... My new room is larger (thankfully) and has the computer within it.

It is good to be back. I feel Melbourne slowly slip away from me...

Prologue...

2005-12-12T19:50:00.000-08:00

On my summer holidays I went to London and America. I watched lots of surgery and I went out lots and I had so much fun and did so much shopping and like, TOTALLY MAXxXed my credit cards! I learnt everything there was to learn about Oncology and Microsurgery and came back a better medical student for it...

The End.

Or did I?